Technical Handbook on Anemia in Adolescents WEEKLY IRON AND FOLIC ACID SUPPLEMENTATION PROGRAMME

Transcription

1 Technical Handbook on Anemia in Adolescents WEEKLY IRON AND FOLIC ACID SUPPLEMENTATION PROGRAMME

2 What is the Weekly Iron and Folic Acid Supplementation (WIFS) Programme? The Ministry of Health and Family Welfare- Government of India has launched the Weekly Iron and Folic Acid Supplementation (WIFS) Programme to address nutritional anaemia among adolescents (age group of 10-19years). This programme will be implemented pan India both rural and urban areas. It will focus on: School Based (Boys and Girls) A. School going adolescent girls and boys in government/government aided/municipal schools from Classes 6 th -12 th Community Based through the Anganwadi Center(Girls only) B. Out of school adolescent girls The WIFS programme will also cover married adolescent girls. Pregnant and lactating adolescent girls will be given IFA supplements, according to current guidelines for antenatal and postnatal care through the existing health system of NRHM. What does the WIFS Strategy involve? Under the WIFS programme for adolescents, IFA supplements are to be distributed free on a weekly basis to the target groups in Categories A and B. In addition to IFA supplements, Albendazole tablets for de-worming are to be administered twice a year, to the same target groups. Administration of weekly iron-folic acid supplements (WIFS).One IFA tablet containing 100mg elemental iron and 500 microgram Folic acid administered on a fixed day through supervised consumption for 52 weeks in a year. Screening of target groups for moderate/severe anaemia and referring these cases to an appropriate health facility. Biannual Albendazole (400mg) for de-worming given six months apart, for control of worm infestation. Information and counseling for improving dietary intake and for taking actions for prevention of intestinal worm infestation. About this Handbook: This handbook provides information on iron deficiency anaemia for NRHM, Education and ICDS programme managers, master trainers, district level trainers, doctors, nurses, and those involved implementing the WIFS programme. This book is a supplement to the Operational Framework for the WIFS programme. Gaining an in-depth knowledge on iron deficiency anaemia will equip the frontline functionaries with skills to counsel and educate adolescents (aged years) about anaemia prevention and control, encourage them to regularly take weekly Iron Folic Acid (IFA) tablets and consume iron rich foods.

3 II ANAEMIA : CAUSES AND EFFECTS Anaemia is a critical public health problem in India that affects women and children throughout the lifecycle. Anaemia in boys and girls limits their development, learning ability, reduces concentration in daily tasks, increases their vulnerability to infection, increases school dropout rates, reduces physical fitness and work productivity. Anaemia in girls during pregnancy is associated with premature births, low birth weight, and peri-natal and maternal mortality. Adolescence is an opportune time for interventions to address anaemia, as it is an important time of growth and development. Missing out on nutrition education and IFA supplementation at this time may push young boys and girls furtherr into the cycle of iron deficiency and anaemia. In adolescent girls, apart from meeting growth needs, sufficient iron intake is also essential before and during pregnancy. What is anaemia? Human blood contains a red pigment called haemoglobin, which is rich in iron. It carries oxygen to different parts of body. Deficiency of iron in diet leads to decreased amount of haemoglobin, making the blood thin and less red in colour which leads to less supply of oxygen to different parts of the body; this state is known as anaemia. Cut off levels of hemoglobin for diagnosis of Anemia Age/Sex Hb Gram/dl Children 6 months to 6 years 11 Children 6 to 14 years 12 Adolescents years 12 Adult male Adult female Adult female pregnant 11 If the level falls below those above, then the person is diagnosed as having anaemia Classification of anaemia according to WHO Mild anaemia 11.9 gm to 10 gmhb /100 ml blood Moderate anaemia 9.9 gm to 7gm Hb /100 ml blood Severe anaemia < 7 gmhb/100 ml blood Anaemia in non-pregnant woman <12 gmhb/100 ml blood (above 15 years of age) Anaemia in pregnant women <11 gmhb/100 ml blood 1

4 Common causes of anaemia There are many different types of anaemia. They could be nutritional or non -nutritional causes (heavy/chronic bleeding, infections, genetic disorders or cancers).nutritional anaemia, particularly, is the most widely prevalent form of anaemia in the country. Causes of Iron Deficiency Anemia and nutritional anaemia are: Poor Dietary intake of iron resulting in deficiency of iron in the body and thus Iron deficiency anaemia (less intake of iron rich foods; Gender discrimination in food allocation in a family aggravates the situation Low bio-availability of iron- Habitual intake of cereal based diet high in phytate and poor consumption of iron absorption enhancers such as vitamin C result in low availability of iron Dietary deficiency of vitamins such as Folic Acid, Vitamin C, Vitamin B12 Non nutritional causes of anaemia: Accelerated increase in requirement for iron during adolescent period Hookworm infestation Infections such as Malaria Loss of blood in case of heavy menstrual bleeding. Teenage marriage and early pregnancy Teenage pregnancy places double burden on the physically and physiologically immature body of girls and results in increasing the likelihood of anaemia, maternal mortality, pregnancy complications and birth of low birth weight babies. Iron Deficiency and Iron Deficiency Anaemia An Overview of Causes Iron Deficiency and Iron Deficiency Anaemia Inadequate dietary intake against very high requirement Intestinal worm infestation Immediate causes Low content of iron, low intake of enhancers High intake of inhibitors Inadequate care of adolescent girls, menstrual loss, early onset conception. Lack of access to health services, clean water and sanitation Underlying causes SOURCE: Vir, Sheila, (2011) Public Health Nutrition in Developing Countries 2

5 Iron deficiency anaemia develops after normal stores of iron have been depleted in the body. Thus the signs of anaemia may not be clinically visible until the anaemia is severe (Hb less than 7-8 gms/dl). 1 However, adverse impact on health occurs even before this stage is reached. Who is affected? The high risk groups for anaemia include- Women of child bearing age who have blood loss through menstruation Pregnant and lactating women who have an increased requirement of iron Adolescents and children who have rapid growth phases People with poor dietary intake of iron through a deficient diet. Intergenerational cycle of Anemia - An adolescent girl who enters the reproductive age with low iron stores and becomes pregnant during adolescence or later is at greater risk of giving birth to a low birth weight and preterm baby. The baby is also borne with low iron stores and further with poor infant feeding practices is more likely to enter adolescence with low iron stores in the body. Thus this vicious cycle of iron deficiency anemia continues Intergenerational cycle of Anemia Adolescent enters reproductive age group with low iron stores. Adolescent with low iron and Hb level + Menstrual blood loss Pregnant woman with anaemia Uncorrected anaemia in infancy and childhood Baby with low iron and haemoglobin levels Women in general are more prone to anaemia than men because of smaller stores of iron and the onset of menstruation imposes additional requirement of Iron to compensate for menstrual blood loss. In Indian girls, the highest prevalence of anaemia is reported between the ages of years which also coincides with the average age of menarche. In girls, the lower total food intake or energy intake by compared to boys, 1 Nelson Textbook of Pediatrics; Volume 1 Chapter Anemia Treatment and Causes 3

6 combined with menstrual losses cause adolescent girls to be at greater risk of Iron deficiency and IDA Signs of anaemia: Definitive diagnosis of anaemia can only be made by a blood test that measures Haemoglobin(Hb) levels in the blood.the test for Hb is carried out in health centres. However there are some signs that may assist in identifying anaemia. They include: Whiteness or pallor in the inner rims of the eyelid, tongue, overall skin, nails, palms of the hand. Soreness of the mouth, with cracks at the corners. Dizziness, tiredness, fatigue and low energy Unusually rapid heartbeat, particularly with exercise Shortness of breath and frequent headaches, particularly with exercise Lack of interest in play and studies Difficulty/ inability to concentrate Leg cramps Lowered resistance to infections Iron deficiency anemia develops after normal stores of iron have been depleted in the body. Thus the signs of anemia may not be clinically visible until the anemia is severe (Hb less than 7-8 gms/dl). 2 However, adverse impact on health occurs even before this stage is reached. How to identify anemia: Pallor of tongue, nail, conjunctiva (lower eyelids) of eyes, fatigue, weakness, dizziness, drowsiness,loss of appetite and swelling (odema) of feet If an adolescent looks pale, fatigued or listless and anemia is suspected, refer her/him to the nearest PHC. III Prevention and Control of Anaemia in Adolescents Primary prevention of anaemia is achieved through well- balanced diet rich in iron and other vitamins and minerals involved in iron absorption or in the production of RBCs/Haemoglobin. a) Balanced diet rich in Iron Adolescence is a significant period for physical growth and sexual maturation. Adolescents need to eat a balanced diet i.e. adiet that provides all nutrients (carbohydrates, proteins, fats, vitamins and minerals) in required amounts and proportions for maintaining health and general well-being. Eating a balanced diet means consuming different types of food items like pulses, chapatti or rice, green vegetables, locally available fruits and milk every day. Functions of various food components and why it is important for adolescents: 2 Nelson Textbook of Pediatrics; Volume 1 Chapter Anemia Treatment and Causes 4

7 Proteins are required for body building and help in repair and maintenance of body tissues. Egg, milk, pulses, fish, meat, ground nut are some examples of body building foods. Fats are high-energy foods and provide fat-soluble vitamins. Oil, ghee, butter, cheese, egg, fat of meat, fish, ground nut oil, and mustard oil are some examples of fat. Carbohydrates form the major component of most diets and are the main source of energy. Rice, potato, sugar, banana, jaggery, sugarcane, honey are the examples. Vitamins and minerals are required in small quantities. They play an important role in growth, repair and regulation of vital body functions. Fruits and vegetables are the examples of protective food. Calcium needs during adolescence is greater in adolescence because of rapid increase in lean body mass and skeletal growth. Milk and milk products are rich source of calcium. Foods rich in iron are (i) Green vegetables and fruits (ii) Grains-wheat, jowar, bajra, sprouted pulses, ground nut, sesame, jaggery, dried fruits (iii) Liver, egg, fish,meat (iv) Vitamin C rich foods help in absorption of iron. Citrus fruits (oranges, lemon), Indian gooseberry (Amla), apple, pear are rich in vitamin C. However given that many of these sources of iron are often not available on a regular basis to most people in our country, eating green vegetables should be emphasized. This is more likely to be widely available even among families with low incomes. It should certainly be part of the meals served in schools and at the Anganwadi Centers. In our Indian diets, the absorption of iron from the diet is poor because of the presence of certain chemical substances. For example tannin in tea can hamper the absorption of iron. On the other hand vitamin C and vitamin C rich foods like amla (Indian gooseberry, lime juice, oranges, and sprouts improve iron absorption. Thus tea, coffee or soda containing drinks should not be consumed immediately before or at least two hours after a meal. Adding Vitamin C rich foods to the meal should be encouraged. b) Iron Supplementation: In India, the poor absorption of iron and a predominantly vegetarian diet means that despite the consumption of a balanced diet, iron supplementation is required to prevent and control anaemia. Anaemia among adolescents can be prevented by regular consumption of iron and folic acid tablets once a week, ideally 52 tablets in a year. This is the basis of the WIFS programme c) Additional interventions: Prevention of malaria: Clean surroundings, use of insecticide treated mosquito net while sleeping helps keep malaria mosquitoes away from people and greatly reduces malaria. 5

8 Prevention and treatment of hookworm infestation: Deworming reduces worm load and blood loss and prevents anemia. To prevent hookworm infestation one should maintain personal hygiene and environmental cleanliness. One should use latrine and avoid open air defecation. Regular consumption of Albendazole 400mg tablet, six months apart, for control of helminthes infestation should be undertaken. Personal hygiene and sanitation, food hygiene Use of clean drinking water can help protect from various infections and diseases. Washing hands with soap water before cooking, consuming food, after defecation and after discarding faecal matter of a child is essential to prevent entry of germs into our abdomen Keeping personal hygiene Preparing and consuming hygienically treated or prepared food Fortification of food with iron (salt, flour, rice, biscuits etc.) d) Early Identification and Referral: Early identification and referral of suspected cases of anaemia constitutes an important measure of secondary prevention of anaemia. Moderate to severe anemia is present if there is: Yellowness of tongue, nail, palm and conjunctiva of eye Fatigue and loss of appetite Breathlessness Swelling (oedema) of feet If anaemia is suspected it is important to refer the adolescent girl/boy to the nearest health facility for further examination. 6